Consent Form Template for Occupational Therapy

Welcome to part four in our series of Occupational Therapy (OT) aimed at helping you run your clinic better! We’ve talked about invoicing, intake, and telehealth consent but this part will go in-depth into consent and payments – at the end, we’ll also provide you an Occupational Therapy consent form template to get started.

I’ll show you what you could have in your consent and payment forms, why it makes sense to combine the two, and an example of the template I use myself.


What is a consent and payment agreement form?

A consent and payment agreement form essentially lets the patient know the details of their care as well as the agreement of responsibility within treatment and for payment with you the occupational therapist. This consent and payment form is supposed to provide transparent information about your services, how you’ll protect their personal health information (PHI), what happens if you need to share information with other healthcare providers, and more.

In addition to an adult occupational therapy consent and payment form template, I’ll also be including one for children for those that work in paediatrics. In Canada, if the patient is younger than 18, a parent or guardian will need to give consent on their behalf. The form itself isn’t much different from an adult’s consent and payment form, but the language is changed to address the patient in third person as they won’t be the ones providing and signing the consent form.


Why does it make sense to combine the two?

This may be a little different than what you’re used to because a lot of Occupational Therapy practitioners will separate their consent and payment forms. I used to be like that when I first started out too, but after running my own private practice for a while I realized that there was a lot of overlap between the two. When you first intake a patient, there’s already so much paperwork to fill out and keep track of, so to make things easier and streamline for both you and your client. So, I combined the consent and payments into one form. 


What should a consent and payment agreement form for occupational therapy include?

Great question! Here are some things you should include in your Consent and Payment Form (and is also included in occupational therapy consent and payment form template below):

  1. Name and purpose of treatment:Your name, profession and the type of treatment that you will be providing to the client. 
  2. Consent for photo/video: In the event that you use video or photos to support assessment or evaluation of clients, you will need their permission, and explain how the video and photos will be used. For example, if you are setting up an environment and need to take a picture of a bathroom to remember the location of the toilet and shower heads for recommending equipment. Or, if you are assessing how a child prints and want to capture how they hold their pencil.
  3. Consent for PHI: What is PHI? Personal health information is health information about an individual that identifies the specific individual, examples include date and location of birth, diagnosis, weight and height, etc.
  4. Consent to sharing information with other healthcare providers: In the spirit of collaboration, you require consent from your client to share and talk with other healthcare providers that are involved in their treatment. We call this third party participation, it could be a Physio, Lawyer, Social Worker, and you would be consulting to support the big picture care of your client. 
  5. Service fees: This is what you will charge for the services you offer, whether it might be treatment, assessment, or documentation. You can choose between billing hourly (for each minute and hour you spend working on the client file, or sessional, where you charge them a higher fee for the session that includes the prep, charting, and communication in between sessions. 
  6. Right to withdraw consent: The ability to withdraw whenever is important, as the client may no longer agree with your treatment plan or methods and no longer provide consent for you to treat them. 

You got into your profession to help others, not to get lost in completing non-billable tasks. Fill out the form below to access the Occupational Therapy consent and payment agreement form template.  What you will notice is I have put together 4 different consent template options, a short and long form for both peds and adults. Please make a copy as these are documents. Enjoy!! 

Disclaimer: This information is freely shared but not to be taken as legal advice. 


As you can probably tell, I’m a huge advocate of automation and while this Occupational Therapy consent and payment form template can help you get started, when you’re ready to take things to the next level with workflow automation, Therabyte is here to help you make that transition!




Looking forward to connecting soon, please reach out with any comments or questions at


Ashley Reina,

Occupational Therapist & Co-founder of Therabyte App


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